John Crown (Independent) | Oireachtas source

The Minister inherited a very difficult job in very difficult circumstances. He set his face into the wind with the reform agenda, which will be difficult to implement. He has and continues to enjoy my confidence.

It is appropriate to point out at this stage that the Minister is the fifth, or possibly sixth, Minister under whom I have worked as a doctor in Ireland since 1996. Of the last four, the current Minister exhibits an extraordinary difference, namely, that his aggregate workplace experience, not just in health care, compares favourably with that of his three predecessors, whose aggregate workplace experience before becoming Members was four years. It was quite extraordinary in that two had worked for less than one academic year as teachers and one had worked for several years in a very reputable legal practice. That was the total life and work experience they brought to the job. We can see the difference in somebody who has not just worked in any workplace but in the health system. It brings understanding to the problems we face.

My one small concern is that the Minister may have been taken captive by the bureaucracy. I came back to Ireland in 1993 to work in a voluntary hospital that answered to the Eastern Health Board, which in turn answered to the Department of Health. After the first of many re-jigs, I worked for a voluntary hospital that answered to a regional health authority that answered to the Department of Health. Subsequently, I worked for a voluntary hospital that answered to the HSE and the Department of Health, and then for a HSE hospital that answered to the HSE itself, which was somehow quasi-independent from the Department of Health. More recently, the proposals are such that I will be working in a HSE hospital under a structure that is ultimately, I am thankful, to be prorogued and absorbed into another body.

Twenty years ago, I worked in a country that had the worst doctor-patient ratios and waiting lists of any country in western Europe. This is still certainly the case in respect of doctor?patient ratios. In the case of waiting lists, we are still close to the bottom. The most recent figures I saw, dating from two years ago, show we are still ranked way below the norm in terms of access to care.

Recent figures have shown that the waiting period for treatment has shortened, which is welcome, but the time taken to gain access to consultants to get the treatment has lengthened. I would love to know the aggregate waiting time from a GP decision that one needs hospital treatment to one's actually obtaining hospital treatment. I suspect it is not very different.

Twenty years ago, I came back to work in a system that was bureaucratised, centralised, undemocratic and corporatised. Regretfully, I still do. Some 20 years ago, new consultants could be appointed only by an entity called Comhairle na nOspidéal. In examining this organisation, one can only assume it was set up in the manner that dogcatchers were appointed in Tipperary after the Second World War to ensure there were no greenshirts or blueshirts being appointed in excessive numbers. The idea that the appointment of a radiologist in Macroom required the approval of a central committee somewhere in Dublin made no sense. The committee now has a different name and is called the HSE; it still makes no sense. As the senior Senator from Cork stated, there are still huge inconsistencies and illogical aspects associated with the appointment of consultants. I hope we can get this fixed.

When I first started speaking about health issues approximately ten years ago, I stated the central problems of the health service could be summed up in three broad silos. I have always believed the health service was of mediocre quality and I never bought into the hysteria suggesting we had a Third World health system. I worked in a Third World system and realise we have never had such a system here. We had a health system that was and sadly is still close to the bottom of the table of western OECD health systems in terms of access, specialist care, etc.

The system is characterised by extraordinary inefficiency. This is a product of our amazingly inefficient system of funding. We basically put in place structural incentives for hospital CEOs to close beds. When the money runs short towards the end of the year, they react by closing beds and operating theatres. This is why I am a little sceptical about the potential impact of some of the nuanced differences proposed for consultant working practices. As I said to my colleagues, they should accept everything they are asked to accept because they will not be doing any more work. The proposal will make no difference. If they sign up to do operations on Saturdays, there will be no theatre or nurses. The beds will be closed and the ambulance drivers will not bring the patients in. I said that if they are going to sign up to the agreement for the sake of industrial peace, they should do so, but that it will actually make no difference.

The third major issue with the health system, the third great pillar of dysfunction, is inequality. It is a case of the Paris Hilton health care system. Paris Hilton said that when she gets on an aeroplane, she wants to turn left and not right. This is the kind of system we have inherited, unfortunately. It is not of the Minister's making and it is one he intends to reform with the move towards universal and negotiable insurance. However, it is the system we have and it needs to be tackled.

There is a great scene in "Father Ted" in which Father Ted receives the Golden Cleric award and has the opportunity to be on the podium for a few minutes, where he vents his views, resulting in a form of group psychotherapy. Bearing this in mind, pardon me if I unburden myself of one or two anecdotes that I believe are illustrative of some of the dysfunctions.

When I came back in 1993, I discovered I was one of only four oncologists in the entire country, which was ludicrous. There was an unbelievable lack of access and patients were dying from treatable cancers. Women were having mastectomies because they could not gain access to radiotherapy for geographical reasons.

Women in County Donegal were more likely to have a mastectomy than women in south County Dublin because they were further away from radiotherapy centres. For approximately six months, I tried to go through the bureaucratic channels to highlight the fact that we needed a fundamental reinvestment in oncology services. I got nowhere, lost my temper and went public. For a year, I became something of a nuisance of a young man making public statements and pointing out grotesque deficiencies.

The reaction of the bureaucracy was not all that strange - it was probably internally consistent. In the first instance, we were called into a meeting. I will not name names, but a senior official at the Department of Health told us that the Minister of the time was unhappy to be reading accounts in newspapers about cancer service deficiencies and asked us to be quiet about them while he thought about what to do. That did not quite sit with me. I was then hauled in by my hospital and told that there had been a serious and credible threat to the effect that a proposed investment in the hospital would be withdrawn if it could not control me. I was told that, only for the fact that I had passed the one-year probationary period on the old consultants' common contract, I would certainly have been fired. It was not because I was an alcoholic or moral reprobate or doing anything illegal, but because I was not toeing the line or being quiet about deficiencies in the system.

I am not satisfied that the current provisions give any more protection than I would have had if I had not passed my one-year initial phase as a consultant. The central problem in our system is that it is undemocratic and bureaucratic. Until we have a truly democratised, liberalised and socially responsive health system with the elimination of most of the bureaucratic middle levels, we will continue to have these problems.

Early on, I heard the argument that I was only a clinician, what was a type of technician, that I did not know the situation and that the only people capable of acting in a self-disinterested fashion were health bureaucrats, civil servants and hospital administrators. Everyone but them had a vested interest. I became so tired of hearing this that I decided to enrol in a relatively arduous two-year MBA programme to study health policy and health management at the Smurfit school. It has been one of my best decisions. The first lesson we were taught on the first day was the difference between management and leadership. I fear that what we are seeing in the health system is layer upon layer of management and a failure of leadership.

The model that is best loved by the permanent government and the hospital administration class has a professional managerialist at the centre surrounded by a group of technicians who do technical jobs - the person who fixes the hospital boiler, the person who is in charge of the kitchen, the person who looks after the laundry, the person who does brain surgeries, the nurse and the radiologist. We need to move to a fundamentally different model. At the core of all of the world's great hospitals are clinical leaders - sometimes nursing rather than medical - who are surrounded by wonderful, technical managerial competence. The people in the latter group provide human resources, corporate governance, compliance, physical plant, etc. However, I do not see that model emerging in Ireland. Instead, a kind of tokenism is creeping into clinical involvement through the notion of clinical directors.

Thankfully, I have had the privilege of working in some of the finest hospitals in the world. The people who rose to their leadership positions did so because they were great leaders, not because they were acceptable to the bureaucrat who wanted to elevate a doctor to that position. Some doctors decide relatively early in their careers to become bureaucrats because they do not like practising medicine. They are scattered liberally across Ireland's health system. Disproportionately, the people who are allegedly the senior decision making doctors in our system are not the ones who have been forged in the fires of peer review or climbed the heights of quality, brilliance and achievement. Instead, they are felt to be the safest hands from the bureaucrats' point of view. This is what I fear is emerging in the development of the clinical directorship model.

My final points relate to what one might call guerilla health economics. Spending money on health care is no worse for an economy than is spending money on cars, white goods or holidays. Why is it that Bloomberg News or CNBC tells us that an increase in consumer spending on cars or holidays in February or an increase in house prices is good news whereas spending more money on health care is bad news? It is always bad to waste money. We need to understand that if we move to a model of reformed health care, we may end up spending more, but we will spend it more efficiently.

The next time the Minister meets any of the Germans, he should tell them, his friends and colleagues, that they can lecture us on how to run our economy and that Ireland will adopt their health system immediately. The synthesis that has emerged between the Minister's pre-election health policy and Labour's health policy is more correctly called the Deutsche model. Germany's model is the most successful of the large countries' health systems in terms of equity, equality and access. In summary, everybody is mandated to have occupation-based health insurance and society pays the premia of those who do not have it. This provides a freely negotiable insurance instrument. One may take it to any doctor or hospital one wishes. One may choose to attend a hospital run by the state, the Red Cross, a Catholic religious order or a university. One also picks one's doctor. Doctors deal with one directly and bill one's insurance. Such a system has risks. Doctors can overdo testing, in that there is a health economic concept called supplier-induced demand. However, there are ways to police that situation.

This is something like the system we have in our socialised health insurance model, namely, VHI, which is a community-rated form of slightly selective social insurance that is open to approximately 45% to 50% of the population.

The big bang that we need to reform the existing system is not that big. We have already gone half way with approximately one half of the population.